Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

metoprolol TARTRATE 25 mg tab [VDMC]

Facility

$1.20

Service Code	HCPCS A9270
Hospital Charge Code	10405605
Hospital Revenue Code	259
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.08
Rate for Payer: Aetna of IA Commercial	$1.08
Rate for Payer: Aetna of IA Medical Rental Products	$1.08
Rate for Payer: Cash Price	$0.96
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.90
Rate for Payer: Medical Associates Commercial	$0.90
Rate for Payer: Midlands Choice Commercial	$0.84
Rate for Payer: United Healthcare Commercial	$1.08

metoprolol TARTRATE 25 mg tab [VDMC]

Facility

$1.20

Service Code	HCPCS A9270
Hospital Charge Code	10405605
Hospital Revenue Code	259
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$1.08
Rate for Payer: Aetna of IA Commercial	$1.08
Rate for Payer: Aetna of IA Medical Rental Products	$1.08
Rate for Payer: Aetna of IA Medicare	$0.68
Rate for Payer: Amerigroup Medicaid	$0.69
Rate for Payer: Amerigroup Medicare	$0.55
Rate for Payer: Cash Price	$0.96
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.90
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.54
Rate for Payer: Iowa Total Care Managed Medicaid	$0.69
Rate for Payer: Medical Associates Commercial	$0.90
Rate for Payer: Medical Associates Managed Medicare	$0.54
Rate for Payer: Midlands Choice Commercial	$0.84
Rate for Payer: Molina Healthcare Managed Medicaid	$0.70
Rate for Payer: Partners Health Alliance Commercial	$0.62
Rate for Payer: United Healthcare Commercial	$1.08
Rate for Payer: United Healthcare Managed Medicare	$0.71

metoprolol TARTRATE 50 mg Tab [VDMC]

Facility

$1.25

Service Code	HCPCS A9270
Hospital Charge Code	10405670
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$1.12
Rate for Payer: Aetna of IA Commercial	$1.12
Rate for Payer: Aetna of IA Medical Rental Products	$1.12
Rate for Payer: Aetna of IA Medicare	$0.71
Rate for Payer: Amerigroup Medicaid	$0.72
Rate for Payer: Amerigroup Medicare	$0.57
Rate for Payer: Cash Price	$1.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.94
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.56
Rate for Payer: Iowa Total Care Managed Medicaid	$0.71
Rate for Payer: Medical Associates Commercial	$0.94
Rate for Payer: Medical Associates Managed Medicare	$0.56
Rate for Payer: Midlands Choice Commercial	$0.87
Rate for Payer: Molina Healthcare Managed Medicaid	$0.72
Rate for Payer: Partners Health Alliance Commercial	$0.65
Rate for Payer: United Healthcare Commercial	$1.12
Rate for Payer: United Healthcare Managed Medicare	$0.74

metoprolol TARTRATE 50 mg Tab [VDMC]

Facility

$1.25

Service Code	HCPCS A9270
Hospital Charge Code	10405670
Hospital Revenue Code	259
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$1.12
Rate for Payer: Aetna of IA Commercial	$1.12
Rate for Payer: Aetna of IA Medical Rental Products	$1.12
Rate for Payer: Cash Price	$1.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.94
Rate for Payer: Medical Associates Commercial	$0.94
Rate for Payer: Midlands Choice Commercial	$0.87
Rate for Payer: United Healthcare Commercial	$1.12

metroNIDAZOLE 500 mg/100 mL IV Sol [VDMC]

Facility

$58.43

Service Code	HCPCS J1836
Hospital Charge Code	10405812
Hospital Revenue Code	259
Min. Negotiated Rate	$26.29
Max. Negotiated Rate	$221.80
Rate for Payer: Aetna of IA Commercial	$52.59
Rate for Payer: Aetna of IA Medical Rental Products	$52.59
Rate for Payer: Aetna of IA Medicare	$33.31
Rate for Payer: Amerigroup Medicaid	$33.70
Rate for Payer: Amerigroup Medicare	$26.56
Rate for Payer: Cash Price	$46.75
Rate for Payer: Cash Price	$46.75
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.82
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$26.29
Rate for Payer: Iowa Total Care Managed Medicaid	$33.38
Rate for Payer: Medical Associates Commercial	$43.82
Rate for Payer: Medical Associates Managed Medicare	$26.29
Rate for Payer: Midlands Choice Commercial	$40.90
Rate for Payer: Molina Healthcare Managed Medicaid	$33.87
Rate for Payer: Partners Health Alliance Commercial	$30.24
Rate for Payer: United Healthcare Commercial	$52.59
Rate for Payer: United Healthcare Managed Medicare	$34.47
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

metroNIDAZOLE 500 mg/100 mL IV Sol [VDMC]

Facility

$58.43

Service Code	HCPCS J1836
Hospital Charge Code	10405812
Hospital Revenue Code	259
Min. Negotiated Rate	$40.90
Max. Negotiated Rate	$52.59
Rate for Payer: Aetna of IA Commercial	$52.59
Rate for Payer: Aetna of IA Medical Rental Products	$52.59
Rate for Payer: Cash Price	$46.75
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.82
Rate for Payer: Medical Associates Commercial	$43.82
Rate for Payer: Midlands Choice Commercial	$40.90
Rate for Payer: United Healthcare Commercial	$52.59

metroNIDAZOLE 500 mg Tab [VDMC]

Facility

$1.26

Service Code	HCPCS A9270
Hospital Charge Code	10405741
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$1.13
Rate for Payer: Aetna of IA Commercial	$1.13
Rate for Payer: Aetna of IA Medical Rental Products	$1.13
Rate for Payer: Aetna of IA Medicare	$0.72
Rate for Payer: Amerigroup Medicaid	$0.72
Rate for Payer: Amerigroup Medicare	$0.57
Rate for Payer: Cash Price	$1.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.94
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.56
Rate for Payer: Iowa Total Care Managed Medicaid	$0.72
Rate for Payer: Medical Associates Commercial	$0.94
Rate for Payer: Medical Associates Managed Medicare	$0.56
Rate for Payer: Midlands Choice Commercial	$0.88
Rate for Payer: Molina Healthcare Managed Medicaid	$0.73
Rate for Payer: Partners Health Alliance Commercial	$0.65
Rate for Payer: United Healthcare Commercial	$1.13
Rate for Payer: United Healthcare Managed Medicare	$0.74

metroNIDAZOLE 500 mg Tab [VDMC]

Facility

$1.26

Service Code	HCPCS A9270
Hospital Charge Code	10405741
Hospital Revenue Code	259
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$1.13
Rate for Payer: Aetna of IA Commercial	$1.13
Rate for Payer: Aetna of IA Medical Rental Products	$1.13
Rate for Payer: Cash Price	$1.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.94
Rate for Payer: Medical Associates Commercial	$0.94
Rate for Payer: Midlands Choice Commercial	$0.88
Rate for Payer: United Healthcare Commercial	$1.13

MG Breast Tissue Specimen Left

Facility

$151.00

Service Code	CPT 76098 LT
Hospital Charge Code	6800837
Hospital Revenue Code	320
Min. Negotiated Rate	$105.70
Max. Negotiated Rate	$135.90
Rate for Payer: Aetna of IA Commercial	$135.90
Rate for Payer: Aetna of IA Medical Rental Products	$135.90
Rate for Payer: Cash Price	$120.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$113.25
Rate for Payer: Medical Associates Commercial	$113.25
Rate for Payer: Midlands Choice Commercial	$105.70
Rate for Payer: United Healthcare Commercial	$135.90

MG Breast Tissue Specimen Left

Facility

$151.00

Service Code	CPT 76098 LT
Hospital Charge Code	6800837
Hospital Revenue Code	320
Min. Negotiated Rate	$67.95
Max. Negotiated Rate	$328.80
Rate for Payer: Aetna of IA Commercial	$135.90
Rate for Payer: Aetna of IA Medical Rental Products	$135.90
Rate for Payer: Aetna of IA Medicare	$86.07
Rate for Payer: Amerigroup Medicaid	$87.10
Rate for Payer: Amerigroup Medicare	$68.63
Rate for Payer: Cash Price	$120.80
Rate for Payer: Cash Price	$120.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$113.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$67.95
Rate for Payer: Iowa Total Care Managed Medicaid	$86.25
Rate for Payer: Medical Associates Commercial	$113.25
Rate for Payer: Medical Associates Managed Medicare	$67.95
Rate for Payer: Midlands Choice Commercial	$105.70
Rate for Payer: Molina Healthcare Managed Medicaid	$87.52
Rate for Payer: Partners Health Alliance Commercial	$78.14
Rate for Payer: United Healthcare Commercial	$135.90
Rate for Payer: United Healthcare Managed Medicare	$89.09
Rate for Payer: Wellmark IA HMO WHPI	$298.49
Rate for Payer: Wellmark IA PPO	$328.80

MG Breast Tissue Specimen Left.

Facility

$151.00

Service Code	CPT 76098 LT
Hospital Charge Code	969777
Hospital Revenue Code	320
Min. Negotiated Rate	$105.70
Max. Negotiated Rate	$135.90
Rate for Payer: Aetna of IA Commercial	$135.90
Rate for Payer: Aetna of IA Medical Rental Products	$135.90
Rate for Payer: Cash Price	$120.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$113.25
Rate for Payer: Medical Associates Commercial	$113.25
Rate for Payer: Midlands Choice Commercial	$105.70
Rate for Payer: United Healthcare Commercial	$135.90

MG Breast Tissue Specimen Left.

Facility

$151.00

Service Code	CPT 76098 LT
Hospital Charge Code	969777
Hospital Revenue Code	320
Min. Negotiated Rate	$67.95
Max. Negotiated Rate	$328.80
Rate for Payer: Aetna of IA Commercial	$135.90
Rate for Payer: Aetna of IA Medical Rental Products	$135.90
Rate for Payer: Aetna of IA Medicare	$86.07
Rate for Payer: Amerigroup Medicaid	$87.10
Rate for Payer: Amerigroup Medicare	$68.63
Rate for Payer: Cash Price	$120.80
Rate for Payer: Cash Price	$120.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$113.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$67.95
Rate for Payer: Iowa Total Care Managed Medicaid	$86.25
Rate for Payer: Medical Associates Commercial	$113.25
Rate for Payer: Medical Associates Managed Medicare	$67.95
Rate for Payer: Midlands Choice Commercial	$105.70
Rate for Payer: Molina Healthcare Managed Medicaid	$87.52
Rate for Payer: Partners Health Alliance Commercial	$78.14
Rate for Payer: United Healthcare Commercial	$135.90
Rate for Payer: United Healthcare Managed Medicare	$89.09
Rate for Payer: Wellmark IA HMO WHPI	$298.49
Rate for Payer: Wellmark IA PPO	$328.80

MG Breast Tissue Specimen Right

Facility

$151.00

Service Code	CPT 76098 RT
Hospital Charge Code	6800840
Hospital Revenue Code	320
Min. Negotiated Rate	$105.70
Max. Negotiated Rate	$135.90
Rate for Payer: Aetna of IA Commercial	$135.90
Rate for Payer: Aetna of IA Medical Rental Products	$135.90
Rate for Payer: Cash Price	$120.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$113.25
Rate for Payer: Medical Associates Commercial	$113.25
Rate for Payer: Midlands Choice Commercial	$105.70
Rate for Payer: United Healthcare Commercial	$135.90

MG Breast Tissue Specimen Right

Facility

$151.00

Service Code	CPT 76098 RT
Hospital Charge Code	6800840
Hospital Revenue Code	320
Min. Negotiated Rate	$67.95
Max. Negotiated Rate	$328.80
Rate for Payer: Aetna of IA Commercial	$135.90
Rate for Payer: Aetna of IA Medical Rental Products	$135.90
Rate for Payer: Aetna of IA Medicare	$86.07
Rate for Payer: Amerigroup Medicaid	$87.10
Rate for Payer: Amerigroup Medicare	$68.63
Rate for Payer: Cash Price	$120.80
Rate for Payer: Cash Price	$120.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$113.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$67.95
Rate for Payer: Iowa Total Care Managed Medicaid	$86.25
Rate for Payer: Medical Associates Commercial	$113.25
Rate for Payer: Medical Associates Managed Medicare	$67.95
Rate for Payer: Midlands Choice Commercial	$105.70
Rate for Payer: Molina Healthcare Managed Medicaid	$87.52
Rate for Payer: Partners Health Alliance Commercial	$78.14
Rate for Payer: United Healthcare Commercial	$135.90
Rate for Payer: United Healthcare Managed Medicare	$89.09
Rate for Payer: Wellmark IA HMO WHPI	$298.49
Rate for Payer: Wellmark IA PPO	$328.80

MG Breast Tissue Specimen Right.

Facility

$151.00

Service Code	CPT 76098 RT
Hospital Charge Code	969780
Hospital Revenue Code	320
Min. Negotiated Rate	$67.95
Max. Negotiated Rate	$328.80
Rate for Payer: Aetna of IA Commercial	$135.90
Rate for Payer: Aetna of IA Medical Rental Products	$135.90
Rate for Payer: Aetna of IA Medicare	$86.07
Rate for Payer: Amerigroup Medicaid	$87.10
Rate for Payer: Amerigroup Medicare	$68.63
Rate for Payer: Cash Price	$120.80
Rate for Payer: Cash Price	$120.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$113.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$67.95
Rate for Payer: Iowa Total Care Managed Medicaid	$86.25
Rate for Payer: Medical Associates Commercial	$113.25
Rate for Payer: Medical Associates Managed Medicare	$67.95
Rate for Payer: Midlands Choice Commercial	$105.70
Rate for Payer: Molina Healthcare Managed Medicaid	$87.52
Rate for Payer: Partners Health Alliance Commercial	$78.14
Rate for Payer: United Healthcare Commercial	$135.90
Rate for Payer: United Healthcare Managed Medicare	$89.09
Rate for Payer: Wellmark IA HMO WHPI	$298.49
Rate for Payer: Wellmark IA PPO	$328.80

MG Breast Tissue Specimen Right.

Facility

$151.00

Service Code	CPT 76098 RT
Hospital Charge Code	969780
Hospital Revenue Code	320
Min. Negotiated Rate	$105.70
Max. Negotiated Rate	$135.90
Rate for Payer: Aetna of IA Commercial	$135.90
Rate for Payer: Aetna of IA Medical Rental Products	$135.90
Rate for Payer: Cash Price	$120.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$113.25
Rate for Payer: Medical Associates Commercial	$113.25
Rate for Payer: Midlands Choice Commercial	$105.70
Rate for Payer: United Healthcare Commercial	$135.90

MG Mammogram Digital Diagnostic Bilat.

Facility

$335.00

Service Code	CPT 77066 50
Hospital Charge Code	969799
Hospital Revenue Code	401
Min. Negotiated Rate	$150.75
Max. Negotiated Rate	$301.50
Rate for Payer: Aetna of IA Commercial	$301.50
Rate for Payer: Aetna of IA Medical Rental Products	$301.50
Rate for Payer: Aetna of IA Medicare	$190.95
Rate for Payer: Amerigroup Medicaid	$193.23
Rate for Payer: Amerigroup Medicare	$152.26
Rate for Payer: Cash Price	$268.00
Rate for Payer: Cash Price	$268.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$251.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$150.75
Rate for Payer: Iowa Total Care Managed Medicaid	$191.35
Rate for Payer: Medical Associates Commercial	$251.25
Rate for Payer: Medical Associates Managed Medicare	$150.75
Rate for Payer: Midlands Choice Commercial	$234.50
Rate for Payer: Molina Healthcare Managed Medicaid	$194.17
Rate for Payer: Partners Health Alliance Commercial	$173.36
Rate for Payer: United Healthcare Commercial	$301.50
Rate for Payer: United Healthcare Managed Medicare	$197.65
Rate for Payer: Wellmark IA HMO WHPI	$197.81
Rate for Payer: Wellmark IA PPO	$217.90

MG Mammogram Digital Diagnostic Bilat.

Facility

$335.00

Service Code	CPT 77066 50
Hospital Charge Code	969799
Hospital Revenue Code	401
Min. Negotiated Rate	$234.50
Max. Negotiated Rate	$301.50
Rate for Payer: Aetna of IA Commercial	$301.50
Rate for Payer: Aetna of IA Medical Rental Products	$301.50
Rate for Payer: Cash Price	$268.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$251.25
Rate for Payer: Medical Associates Commercial	$251.25
Rate for Payer: Midlands Choice Commercial	$234.50
Rate for Payer: United Healthcare Commercial	$301.50

MG Mammogram Digital Diagnostic Left.

Facility

$294.00

Service Code	CPT 77065 LT
Hospital Charge Code	969801
Hospital Revenue Code	401
Min. Negotiated Rate	$132.30
Max. Negotiated Rate	$264.60
Rate for Payer: Aetna of IA Commercial	$264.60
Rate for Payer: Aetna of IA Medical Rental Products	$264.60
Rate for Payer: Aetna of IA Medicare	$167.58
Rate for Payer: Amerigroup Medicaid	$169.58
Rate for Payer: Amerigroup Medicare	$133.62
Rate for Payer: Cash Price	$235.20
Rate for Payer: Cash Price	$235.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$220.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$132.30
Rate for Payer: Iowa Total Care Managed Medicaid	$167.93
Rate for Payer: Medical Associates Commercial	$220.50
Rate for Payer: Medical Associates Managed Medicare	$132.30
Rate for Payer: Midlands Choice Commercial	$205.80
Rate for Payer: Molina Healthcare Managed Medicaid	$170.40
Rate for Payer: Partners Health Alliance Commercial	$152.14
Rate for Payer: United Healthcare Commercial	$264.60
Rate for Payer: United Healthcare Managed Medicare	$173.46
Rate for Payer: Wellmark IA HMO WHPI	$197.81
Rate for Payer: Wellmark IA PPO	$217.90

MG Mammogram Digital Diagnostic Left.

Facility

$294.00

Service Code	CPT 77065 LT
Hospital Charge Code	969801
Hospital Revenue Code	401
Min. Negotiated Rate	$205.80
Max. Negotiated Rate	$264.60
Rate for Payer: Aetna of IA Commercial	$264.60
Rate for Payer: Aetna of IA Medical Rental Products	$264.60
Rate for Payer: Cash Price	$235.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$220.50
Rate for Payer: Medical Associates Commercial	$220.50
Rate for Payer: Midlands Choice Commercial	$205.80
Rate for Payer: United Healthcare Commercial	$264.60

MG Mammogram Digital Diagnostic Right.

Facility

$294.00

Service Code	CPT 77065 RT
Hospital Charge Code	969803
Hospital Revenue Code	401
Min. Negotiated Rate	$205.80
Max. Negotiated Rate	$264.60
Rate for Payer: Aetna of IA Commercial	$264.60
Rate for Payer: Aetna of IA Medical Rental Products	$264.60
Rate for Payer: Cash Price	$235.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$220.50
Rate for Payer: Medical Associates Commercial	$220.50
Rate for Payer: Midlands Choice Commercial	$205.80
Rate for Payer: United Healthcare Commercial	$264.60

MG Mammogram Digital Diagnostic Right.

Facility

$294.00

Service Code	CPT 77065 RT
Hospital Charge Code	969803
Hospital Revenue Code	401
Min. Negotiated Rate	$132.30
Max. Negotiated Rate	$264.60
Rate for Payer: Aetna of IA Commercial	$264.60
Rate for Payer: Aetna of IA Medical Rental Products	$264.60
Rate for Payer: Aetna of IA Medicare	$167.58
Rate for Payer: Amerigroup Medicaid	$169.58
Rate for Payer: Amerigroup Medicare	$133.62
Rate for Payer: Cash Price	$235.20
Rate for Payer: Cash Price	$235.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$220.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$132.30
Rate for Payer: Iowa Total Care Managed Medicaid	$167.93
Rate for Payer: Medical Associates Commercial	$220.50
Rate for Payer: Medical Associates Managed Medicare	$132.30
Rate for Payer: Midlands Choice Commercial	$205.80
Rate for Payer: Molina Healthcare Managed Medicaid	$170.40
Rate for Payer: Partners Health Alliance Commercial	$152.14
Rate for Payer: United Healthcare Commercial	$264.60
Rate for Payer: United Healthcare Managed Medicare	$173.46
Rate for Payer: Wellmark IA HMO WHPI	$197.81
Rate for Payer: Wellmark IA PPO	$217.90

MG Mammogram Digital Screening Bilat.

Facility

$302.00

Service Code	CPT 77067
Hospital Charge Code	969805
Hospital Revenue Code	403
Min. Negotiated Rate	$211.40
Max. Negotiated Rate	$271.80
Rate for Payer: Aetna of IA Commercial	$271.80
Rate for Payer: Aetna of IA Medical Rental Products	$271.80
Rate for Payer: Cash Price	$241.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$226.50
Rate for Payer: Medical Associates Commercial	$226.50
Rate for Payer: Midlands Choice Commercial	$211.40
Rate for Payer: United Healthcare Commercial	$271.80

MG Mammogram Digital Screening Bilat.

Facility

$302.00

Service Code	CPT 77067
Hospital Charge Code	969805
Hospital Revenue Code	403
Min. Negotiated Rate	$135.90
Max. Negotiated Rate	$271.80
Rate for Payer: Aetna of IA Commercial	$271.80
Rate for Payer: Aetna of IA Medical Rental Products	$271.80
Rate for Payer: Aetna of IA Medicare	$172.14
Rate for Payer: Amerigroup Medicaid	$174.19
Rate for Payer: Amerigroup Medicare	$137.26
Rate for Payer: Cash Price	$241.60
Rate for Payer: Cash Price	$241.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$226.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$135.90
Rate for Payer: Iowa Total Care Managed Medicaid	$172.50
Rate for Payer: Medical Associates Commercial	$226.50
Rate for Payer: Medical Associates Managed Medicare	$135.90
Rate for Payer: Midlands Choice Commercial	$211.40
Rate for Payer: Molina Healthcare Managed Medicaid	$175.04
Rate for Payer: Partners Health Alliance Commercial	$156.28
Rate for Payer: United Healthcare Commercial	$271.80
Rate for Payer: Wellmark IA HMO WHPI	$197.81
Rate for Payer: Wellmark IA PPO	$217.90

MG Mammogram Digital Screening Left.

Facility

$302.00

Service Code	CPT 77067 52\|LT
Hospital Charge Code	4570784
Hospital Revenue Code	403
Min. Negotiated Rate	$135.90
Max. Negotiated Rate	$271.80
Rate for Payer: Aetna of IA Commercial	$271.80
Rate for Payer: Aetna of IA Medical Rental Products	$271.80
Rate for Payer: Aetna of IA Medicare	$172.14
Rate for Payer: Amerigroup Medicaid	$174.19
Rate for Payer: Amerigroup Medicare	$137.26
Rate for Payer: Cash Price	$241.60
Rate for Payer: Cash Price	$241.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$226.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$135.90
Rate for Payer: Iowa Total Care Managed Medicaid	$172.50
Rate for Payer: Medical Associates Commercial	$226.50
Rate for Payer: Medical Associates Managed Medicare	$135.90
Rate for Payer: Midlands Choice Commercial	$211.40
Rate for Payer: Molina Healthcare Managed Medicaid	$175.04
Rate for Payer: Partners Health Alliance Commercial	$156.28
Rate for Payer: United Healthcare Commercial	$271.80
Rate for Payer: Wellmark IA HMO WHPI	$197.81
Rate for Payer: Wellmark IA PPO	$217.90

Know your out-of-pocket cost for care.

All Charges